Method to reduce mitral regurgitation

ABSTRACT

A distal end of a guide catheter is transvascularly advanced into a left ventricle of a heart of a subject. While the distal end of the guide catheter remains disposed in the left ventricle, a first tissue anchor of an implant is deployed from the distal end of the guide catheter. Subsequently, the guide catheter is retracted while progressively exposing the implant. Subsequently, a second tissue anchor of the implant is anchored to a posterior annulus of a mitral valve of the heart by deploying at least part of the second anchor within a left atrium of the heart, such that the implant extends from the first tissue anchor, over an atrial side of a posterior leaflet of the mitral valve, and to the second tissue anchor. Other embodiments are also described.

This application claims the priority of U.S. Provisional PatentApplication Ser. No. 61/035,201, filed on Mar. 10, 2008 (pending), thedisclosure of which is incorporated by reference herein.

TECHNICAL FIELD

The present invention generally relates to surgical methods of securingtissue anchors for reducing the size of an orifice through a tissue and,more particularly, methods of securing tissue anchors for reducing thecircumferential orifice of the mitral valve during an annuloplastysurgical procedure.

BACKGROUND

The mitral valve is composed of valve leaflets, or flaps of tissue, thatopen and close tightly to ensure that the flow of blood through theheart is in one direction only. The leaflets are held in position by aring of tissue, the annulus, surrounding and attaching the leaflets tothe walls of the heart between the left atrium and left ventricle.Chordae tendineae are tendons that tether the leaflets to papillarymuscles within the left ventricle, which prevent the leaflets fromprolapsing into the left atrium. A dysfunction of any one of theseportions of the mitral valve anatomy can cause mitral regurgitation, orthe partial backflow of blood from the left ventricle into the leftatrium. Depending on the severity of the condition, the individual mayexperience a range of symptoms, including shortness of breath, pulmonaryedema, or decreased exercise tolerance.

Surgical procedures may be used for reducing mitral regurgitation. Someof these procedures have included plicating the mitral valve tissue inorder to reduce the size of the orifice created between the leaflets.One such surgical procedure, annuloplasty, is particularly useful intreating mitral valve regurgitation. Annuloplasty modifies the annulus,through one or more plications, and this can return the valve to afunctional geometry.

However, many annuloplasty procedures are highly invasive and mayincorporate open heart surgery, which poses significant risk to thepatient. Therefore, there is a need for a less invasive approach forplicating tissue by eliminating the need for open heart surgery whilereturning the mitral valve to a functional geometry.

SUMMARY

In one illustrative embodiment of the present invention, a method ofrepairing the mitral heart valve is described. The method includessecuring a first tissue anchor to a position on a posterior portion ofthe annulus of the mitral valve and a second tissue anchor to a positionon an anterior portion of the annulus of the mitral valve. At least onetensile member is spanned between the first and second tissue anchorsand across the orifice of the mitral valve. When tension is applied tothe at least one tensile member, the posterior portion of the annulus ispulled toward the anterior portion of the annulus.

In another illustrative embodiment of the present invention, a secondmethod of repairing the mitral heart valve is described. This secondmethod includes directing a guide-wire into the left ventricle, across aposition on a posterior portion of the annulus, through the left atrium,across a position on the anterior portion of the annulus, and thenreturning into the left ventricle. A first tissue anchor is directedalong the guide-wire to the position on the anterior portion of theannulus and secured. A second tissue anchor is then directed along theguide-wire to the position on the posterior portion of the annulus andsecured. At least one tensile member is spanned between the first andsecond tissue anchors and across the orifice of the mitral valve. Whentension is applied to the at least one tensile member, the posteriorportion of the annulus is pulled toward the anterior portion of theannulus.

In another illustrative embodiment of the present invention, a thirdmethod of repairing the mitral heart valve is described. This thirdmethod includes directing a guide-wire into the right atrium, across theintra-atrial septum, into the left atrium to a position on the posteriorportion of the annulus. A first tissue anchor is directed along theguide-wire to the position on the posterior portion of the annulus andsecured. A second guide-wire is then directed into the right atrium,across the intra-atrial septum, into the left atrium to a position onthe anterior portion of the annulus. A second tissue anchor is directedalong the second guide-wire to the position on the anterior portion ofthe annulus and secured. At least one tensile member is spanned betweenthe first and second tissue anchors and across the orifice of the mitralvalve. When tension is applied to the at least one tensile member, theposterior portion of the annulus is pulled toward the anterior portionof the annulus.

BRIEF DESCRIPTION OF THE DRAWINGS

FIGS. 1-6 are respective fragmentary cross-sectional views of the heartillustrating successive steps of one exemplary procedure for advancingand securing first and second tissue anchors to the posterior andanterior annulus, respectively, of the mitral valve.

FIGS. 7-8 are respective fragmentary cross-sectional views of the heartillustrating successive steps of one exemplary procedure for reducingthe size of the mitral valve orifice by tensioning the tensile membersextending between the first and second tissue anchors.

FIG. 9 is an enlarged cross-sectional view of the repaired mitral valveresulting from the procedures illustrated in FIGS. 1-8.

FIGS. 10-13 are respective fragmentary cross-sectional views of theheart illustrating successive steps of another exemplary procedure foradvancing and securing first and second tissue anchors to the posteriorand anterior portions of the annulus, respectively, of the mitral valve.

FIG. 14 is an enlarged cross-sectional view of the heart illustratingthe first and second tissue anchors secured to the posterior andanterior annulus, resulting from the procedure illustrated in FIGS.10-13.

FIG. 15 is an enlarged cross-sectional view illustrating an exemplarymethod of reducing the size of the mitral valve orifice by tensioning atensile member extending between the first and second tissue anchors.

FIG. 16 is an enlarged cross-sectional view of the repaired mitral valveresulting from the procedure shown in FIGS. 10-15.

FIG. 17A is a top view illustrating the mitral valve from the leftatrium before tissue plication and with the first and second tissueanchors positioned at the P3 and A3 regions, respectively.

FIG. 17B is a top view illustrating the mitral valve from the leftatrium after tissue plication and with the first and second tissueanchors positioned at the P3 and A3 regions, respectively.

FIG. 170 is a top view illustrating the mitral valve from the leftatrium after tissue plication and with the first and second tissueanchors positioned at the P1 and A1 regions, respectively.

FIG. 170 is a top view illustrating the mitral valve from the leftatrium after tissue plication with the first and second tissue anchorspositioned at the P3 and A3 regions, respectively, and third and fourthtissue anchors positioned at the P1 and A1 regions, respectively.

FIG. 17E is a top view lustrating the mitral valve from the left atriumafter tissue plication and with a first staple positioned between the P3and A3 regions and a second staple positioned between the P1 and A1regions.

DETAILED DESCRIPTION

The method begins in FIG. 1 by percutaneously accessing the right atrium10 of the heart 14 from a suitable venous access site. The venous accesssite can be located near the jugular vein, superiorly, from the femoralvein, inferiorly, or from other suitable superficial veins. A firstguide-wire 18 is directed into the venous access site, through theinferior or superior vena cava 22, 26, as appropriate, and into theright atrium 10. Suitable guide-wires 18 can includecommercially-available guide-wires commonly used in catheter-basedprocedures, including steerable guide-wires. The first guide-wire 18 canthen be directed across the intra-atrial septum 30, for example near thefossa ovalis 34, and into the left atrium 38 in accordance with knowntransseptal procedures.

Though not specifically shown, the first guide-wire 18 can alternativelybe directed into the left atrium 38 through other known venous accesssites, such as the coronary sinus 42.

After the first guide-wire 18 is in position, a guide catheter 46 can beadvanced over the first guide-wire 18 and into the left atrium 38. Theguide catheter 46 can be any suitable catheter that can be directedthrough the vascular system to aid in the delivery of subsequentsurgical devices, such as tissue anchors 50, 52 (FIG. 3 and FIG. 5) foruse with the procedures described herein. Though not specifically shown,a physician can also use additional surgical instruments, such as anobturator, to sufficiently dilate the puncture through the intra-atrialseptum 30 to accommodate the larger diameter guide catheter 46.

If desired, the physician can confirm the in vivo location of the guidecatheter 46 during any portion of the surgical procedure by visualizinga suitable fluoroscopic marker on the distal end of the guide catheter46 in a known manner.

Turning now to FIG. 2 with the guide catheter 46 positioned within theleft atrium 38, a second guide-wire 54 can then be directed through thelumen of the guide catheter 46 and into the left atrium 38.

FIGS. 2-8 illustrate a first embodiment of a method to repair the mitralvalve 56. The first guide-wire 18 can be directed to a position on aposterior portion of the annulus (i.e. the posterior annulus 66) betweenthe posterior and anterior commissures 59, 60. One skilled in the artmay generally refer to the illustrated position as the P1 region, whichis located laterally at the base of the posterior leaflet 62 along theposterior annulus 66. Another suitable position could be the P3 region,which is located medially at the base of the posterior leaflet 62 andproximal to the intra-atrial septum 30. However, the procedure shouldnot be considered limited to these regions of the posterior annulus 66as one or more regions may be chosen depending on the location of theenlarged orifice through the orifice of the mitral valve 56. Forexample, if the posterior and anterior leaflets 62, 70 do not coapt at alateral region of the mitral valve 56, then the repair can be directedto the A1 to P1 regions; and if the posterior and anterior leaflets 62,70 do not coapt medially, then the repair can be directed moreappropriately to the A3 to P3 regions.

In the illustrated example of FIGS. 2-8, once the first guide-wire 18 isdirected to the desired position on the posterior annulus 66, the firstguide-wire 18 is then advanced across the posterior annulus 66 and intothe left ventricle 48.

In a similar manner, the second guide-wire 54 can be directed to aposition on an anterior portion of the annulus (i.e. the anteriorannulus 74) between the posterior and anterior commissures 59, 60. Theposition of the second guide-wire 54 on the anterior annulus 74 can bespaced between the posterior and anterior commissures 59, 60 at adistance that is similar to the position and spacing of the firstguide-wire 18 on the posterior annulus 66. For example, if theguide-wire 18 is positioned near the P1 region, then the secondguide-wire 54 is positioned near the A1 region, which is locatedlaterally at the base of the anterior leaflet 70 along the anteriorannulus 74. Alternatively, if the first guide-wire 18 is positioned nearthe P3 region, then the second guide-wire 54 is positioned near the A3region, which is located medially at the base of the anterior leaflet 70and proximal to the intra-atrial septum 30.

Once the second guide-wire 54 is directed to the desired position on theanterior annulus 74, the second guide-wire 54 is then advanced acrossthe anterior annulus 74 and into the left ventricle 48.

Though not shown, the physician can, if desired, use known in vivalocalization techniques in directing the guide-wires 18, 54 to thedesired locations along the posterior and anterior portions of theannulus 66, 74. Additionally, the guide-wires 18, 54 can include aradio-frequency (RF) energy delivery tip to assist with penetrationthrough mitral tissue. For this purpose, a suitable RF energy device maybe coupled to one or both of the guide-wires 18, 54. In yet otherembodiments, the distal tip of the guide-wires 18, 54 can be preformedto curl back on itself to help prevent tissue damage after crossing themitral valve tissue and entering the left ventricle 48.

Turning now to FIG. 3, where the advancement and deployment of the firsttissue anchor 50 is shown and described. While any tissue anchor deviceknown in the art can be used, including but not limited to clips, wires,or staples, the particular tissue anchor device shown is collapsible andcomprises a plurality of discrete, flat, flexible anchor elements 78coupled by a flexible tensile member 82. The anchor elements 78 can beformed from a surgical grade fabric material (e.g., a polyester materialsuch as DACRON) designed to promote tissue in-growth so that the anchor50 becomes essentially encased in tissue over time. The anchor elements78 are coupled to the tensile member 82, in this example a suture, bythreading the suture upwardly through the anchor elements 78 and thenback downwardly through the anchor elements 78. A slip knot is thenformed, or another type of lock member is used, so that when a proximalend portion of the tensile member 82 is pulled, all of the anchorelements 78 will be drawn together against opposite sides of the annulartissue. This leaves a long “tail” of the suture leading to the venousaccess site for subsequent tensioning and plication, as will bedescribed below.

In some embodiments, one or more of the anchor elements 78 can include aradiopaque marker for in vivo visualization under a suitable viewingdevice during the procedure. For example, one such marker can be locatedon a proximal portion of the tissue anchor 50 and another marker can belocated on a distal portion of the tissue anchor 50.

In use, the first tissue anchor 50 with a delivery sheath 86 is directedalong the first guide-wire 18, across the posterior annulus 66, and intothe left ventricle 48. The first tissue anchor 50 is then at leastpartially deployed from the delivery sheath 86 on the left ventricularside of the posterior annulus 66. As necessary, the first guide-wire 18can be removed before or after the tissue anchor deployment process.Once a sufficient portion of the first tissue anchor 50 has beendeployed within the left ventricle 48, the physician can stop deployingthe anchor elements 78, slightly retract the delivery sheath 86 backacross the posterior annulus 66 into the left atrium 38, and then deploythe remainder of the anchor elements 78 of the tissue anchor 50 withinthe left atrium 38, as shown in FIG. 4.

In FIG. 5, the physician pulls on the proximal end portion of thetensile member 82 such that the anchor elements 78 of the first tissueanchor 50 are drawn together against opposite sides of the annulartissue, thereby securing the first tissue anchor 50 to the P1 region ofthe posterior annulus 66.

Also shown in FIG. 5, once the first tissue anchor 50 is secured, thephysician can then begin directing the second tissue anchor 52, with adelivery sheath 90, along the second guide-wire 54, across the anteriorannulus 74, and into the left ventricle 48. As described above, thesecond tissue anchor 52 is then at least partially deployed from thedelivery sheath 90 within the left ventricle 48, the delivery sheath 90is then retracted back across the anterior annulus 74, and the remainderof the second tissue anchor 52 is deployed within the left atrium 38.

While the second tissue anchor 52 has been shown to be similar to thefirst tissue anchor 50, it would be understood that a different tissueanchor device structure, or manner of deployment, could be used.

In FIG. 6, after the second tissue anchor 52 has been deployed andsecured to the anterior annulus 74 by a tensile member 94, the physiciancan then retract the delivery sheath 90 from the surgical site.

With both the first and second tissue anchors 50, 52 secured to theirrespective positions on the posterior and anterior portions of theannulus 66, 74, respectively, the physician can then plicate the tissue,as shown in FIG. 7. To plicate the tissue, the physician can pull on therespective proximal end portions of the tensile members 82, 94 such thatthe posterior annulus 66 is pulled toward the anterior annulus 74. Theplication and position of the tissue can be maintained by directing asuture locker 98 along the tensile members 82, 94 to the surgical site.The advancing of the suture locker 98 can be accomplished with adelivery catheter 102 in accordance with known methods. Suitable suturelockers 98 can include those shown in U.S. application Ser. No.11/425,731, which allows the physician to lock the tension andsimultaneously cut the tensile members 82, 94 to an appropriate length,or the suture locker 98 described in U.S. application Ser. No.11/753,921, which includes a locker body having a passageway throughwhich the tensile members 82, 94 extend and a slidable member that movesfrom a latent condition to an activated condition to lock the positionof the tensile members 82, 94 relative to the locker 98.

FIG. 8 illustrates the surgical site after the suture locker 98 is inposition, the tensile members 82, 94 are locked relative to the suturelocker 98, the tensile members 82, 94 have been cut, and the deliverycatheter 102 retracted. This is also illustrated, with an enlarged view,in FIG. 9. As shown, the first and second tissue anchors 50. 52 aresecured and tensioned with the locker 98 such that the posterior andanterior leaflets 62, 70 come into contact and mitral regurgitation isreduced.

Though not specifically shown, the physician can then direct an atrialseptal defect closure device to the intra-atrial septum 30 to seal theorifice created by the guide catheter 46 after it has been retractedfrom the surgical site. Atrial septal defect closure devices are knowngenerally, and can include commercially-available examples such as theBIOSTAR by NMT Medical, Inc. or the AMPLATZER Septal Occluder by AGAMedical Corp.

With the first method of repairing the mitral valve 56 described withsome detail, a second exemplary surgical procedure for repairing themitral valve 56 can now be described with reference to FIGS. 10-13. Inthis method of repairing the mitral valve 56, the physician approachesthe mitral valve 56 from within the left ventricle 48.

FIG. 10 illustrates the directing of a guide-wire 106 into the leftventricle 48, across the mitral valve 56, and into the left atrium 38.This can be accomplished in a known way, such as directing theguide-wire 106 from a suitable arterial access site located near thefemoral or iliac arteries. The guide-wire 106 is directed from thearterial access site to the aorta 110, around the aortic arch 114,through the aortic valve 118, and between the pair of chordae tendineae122 in the left ventricle 48. As described previously, the guide-wire106 is then followed by a guide catheter 126.

Though not specifically shown, the percutaneous access can alternatelybe made from a superior arterial access site so that the guide-wire 106is directed into the aortic arch 114 from the brachiocephalic trunk 130,the left common carotid 134, or the left subclavian arteries 138.

Once the guide-wire 106 is within the left ventricle 48, it can besteered through the volume of the left ventricle 48 to the mitral valve56. More specifically, the guide-wire 106 is steered to cross the mitralvalve 56 at the posterior annulus 66. While the mitral valve 56 can becrossed at several locations, it is preferred that the guide-wire 106crosses the posterior annulus 66 between the anterior and posteriorcommissures 74, 66 at approximately the P1 region, as shown in FIG. 10.While this embodiment of the present invention has been illustrated withthe guide-wire 106 crossing the P1 region, it would be understood thatother regions of the posterior annulus 66, i.e. the P2 or P3 regions,could also be used if appropriate. The P1 region can be localized invivo through fluoroscopy while the physician advances the guide-wire 106across the P1 region and into the left atrium 38. As noted above, ifdesired, the guide-wire 106 can have a radio-frequency (RF) energydelivery tip for assisting with penetration through mitral tissue.

After the guide-wire 106 enters the left atrium 38, it is steeredthrough the volume of the left atrium 38 to the A1 region of theanterior annulus 74. The guide-wire 106 then crosses the anteriorannulus 74 at the A1 region and reenters the left ventricle 48.

As shown in FIG. 11, with the guide-wire 106 properly positioned, thesurgeon can direct a first tissue anchor 156 with the delivery catheter158 through the guide catheter 126, along the guide-wire 106, across theA1 region, and into the left ventricle 48. While any suitable tissueanchor device can be used, the tissue anchor 156 illustrated is the sameas those described above. Accordingly, the first tissue anchor 156 is atleast partially deployed from the delivery catheter 158 on the leftventricular side of the anterior annulus 74. As necessary, theguide-wire 106 can be removed before or after the tissue anchordeployment process. Once a sufficient portion of the first tissue anchor156 has been deployed within the left ventricle 48, the physician canstop deploying, retract the delivery catheter 158 back across theanterior annulus 74 into the left atrium 38, and then deploy theremainder of the first tissue anchor 156 within the left atrium 38, asshown in FIG. 12.

FIG. 12 also illustrates that the physician can then pull on theproximal end portion of the tensile member 162 of the first tissueanchor 156 such that the first tissue anchor 156 is secured to the A1region of the anterior annulus 74.

FIG. 13 illustrates the directing and deploying of a second tissueanchor 166 along the tensile member 162 at the P1 region of theposterior annulus 66. As shown, the second tissue anchor 166 has astructure that is similar to the first tissue anchor 156; however, thisis not required. Thus, deployment of the second tissue anchor 166 canoccur in a manner similar to the procedures described above.

FIG. 14 is an enlarged view of the mitral valve 56 with the first andsecond tissue anchors 156, 166 positioned and secured to the anteriorand posterior portions of the annulus 74, 66, respectively. The tensilemembers 162, 170 of the first and second tissue anchors 156, 166,respectively, extend proximally from the surgical site, through theguide catheter 126 to the incision site.

In FIG. 15, the physician pulls proximally on the tensile members 162,170, such that the A1 and P1 regions are pulled together, the anteriorand posterior leaflets 70, 62 coapt, and mitral regurgitation isreduced. FIG. 15 further illustrates the advancing of a suitable locker174 with a delivery catheter 178 to the surgical site such that thereduction in the size of the mitral valve 56 is maintained. The locker174 can be any suitable suture locker device, including those describedpreviously. The tensile members 162, 170 are then cut to an appropriatelength and the surgical device retracted from the surgical site. Theresult of the surgical procedure, illustrated in FIG. 16, is the firstand second tissue anchors 156, 166 are secured to the annular tissue,and the tensile member 162, 170 extending from the first and secondtissue anchors 156, 166 are sufficiently tensioned such that theanterior and posterior leaflets 70, 62 coapt and mitral regurgitation isreduced or eliminated.

While the methods of mitral valve repair have been described andillustrated primarily with the tissue anchor devices being located atthe A1 and P1 regions of the annular tissue, it would be understood thatother regions of annular tissue could also be used. For example, FIG.17A illustrates the mitral valve 56 from within the left atrium 38having tissue anchors 182, 186 positioned substantially near the P3region of the posterior annulus 66 and A3 region of the anterior annulus74, respectively, and prior to repair of the mitral valve 56.Accordingly, tensile members 188, 190 extend from the tissue anchors182, 186, but are not yet tensioned. FIG. 17B illustrates the tensioningand locking of the tensile members 188, 190 with a suitable locker 194,such as those described previously. Accordingly, the posterior annulus66 is pulled toward the anterior annulus 74 and mitral regurgitation isreduced.

FIG. 170 illustrates tissue anchors 198, 202 positioned substantiallynear the P1 region of the posterior annulus 66 and A1 region of theanterior annulus 74, respectively, as described in the methods above.Tensile members 206, 208 are tensioned and locked with a suitable locker212 such that the posterior annulus 66 is pulled toward the anteriorannulus 74 and mitral regurgitation is reduced.

As discussed above, the positions of the tissue anchor devices would beprimarily determined by the location of the largest orifice through themitral valve 56. That is, if the posterior and anterior leaflets 62, 70do not coapt near the posterior commissure 59, then tissue anchors 182,186 positioned at the A3 and P3 regions can provide the most beneficialrepair; if the posterior and anterior leaflets 62, 70 do not coapt nearthe anterior commissure 60, then tissue anchors 198, 202 positioned atthe A1 and P1 regions can provide the most beneficial repair. However,if the posterior and anterior leaflets 62, 70 do not coapt at a positionthat is between the posterior and anterior commissures 59, 60, or ifthere is more than one region at which the leaflets 62, 70 do not coapt,then one or more regions can be chosen to include additional tissueanchors to effectuate a mitral valve repair.

One example, shown in FIG. 17D, illustrates the use of four tissueanchors 182, 186, 198, 202, and can be the combination of theembodiments shown in FIGS. 17B-C. The use of four tissue anchors 182,186, 198, 202, spanning the mitral valve 56 at two regions, as shown,can provide improved reduction in the mitral valve size and furtherreduce mitral regurgitation. Also, as shown in FIG. 17D, the position ofthe lockers 194, 212 can be adjusted to the particular needs orpreferences of the physician.

Alternatively, FIG. 17E illustrates the use of first and second legs214, 216 and the base 218 of two staples as the tissue anchor andtensile members, respectively. The first and second staples can bepositioned in a manner that is similar to the tissue anchors 182, 186,198, 202 of FIG. 17D to pull the posterior annulus 66 toward theanterior or annulus 74 and effectuate mitral valve repair.

While the present invention has been illustrated by a description ofvarious preferred embodiments and while these embodiments have beendescribed in some detail, it is not the intention of the Applicants torestrict or in any way limit the scope of the appended claims to suchdetail. Additional advantages and modifications will readily appear tothose skilled in the art. The various features of the invention may beused alone or in any combination depending on the needs and preferencesof the user. This has been a description of the present invention, alongwith the preferred methods of practicing the present invention ascurrently known. However, the invention itself should only be defined bythe appended claims.

1-31. (canceled)
 32. A method for use at a mitral valve of a heart of asubject, the method comprising: transvascularly advancing a distal endof a guide catheter into a left ventricle of the heart; and implantingan implant in the heart by: while the distal end of the guide catheterremains disposed in the left ventricle, deploying a first tissue anchorof the implant from the distal end of the guide catheter; subsequently,retracting the guide catheter while progressively exposing the implant;and subsequently, anchoring a second tissue anchor of the implant to aposterior annulus of the mitral valve by deploying at least part of thesecond anchor within a left atrium of the heart, such that the implantextends from the first tissue anchor, over an atrial side of a posteriorleaflet of the mitral valve, and to the second tissue anchor.
 33. Themethod according to claim 32, further comprising transvascularlyadvancing the distal end of the guide catheter into the left atrium ofthe heart, wherein transvascularly advancing the distal end of the guidecatheter into the left ventricle comprises advancing the distal end ofthe guide catheter from the left atrium into the left ventricle.
 34. Themethod according to claim 32, wherein anchoring the second tissue anchorto the posterior annulus comprises anchoring the second tissue anchor toa P1 region of the posterior annulus.
 35. The method according to claim32, wherein anchoring the second tissue anchor to the posterior annuluscomprises anchoring the second tissue anchor to a P2 region of theposterior annulus.
 36. The method according to claim 32, whereinanchoring the second tissue anchor to the posterior annulus comprisesanchoring the second tissue anchor to a P3 region of the posteriorannulus.
 37. The method according to claim 32, wherein the implantincludes a fabric, and wherein implanting the implant comprisesimplanting the implant that includes the fabric.
 38. The methodaccording to claim 37, wherein the fabric includes polyester, andwherein implanting the implant comprises implanting the implant thatincludes the fabric that includes polyester.
 39. The method according toclaim 32, wherein the implant includes a tensile member that extendsbetween the first tissue anchor and the second tissue anchor, andwherein anchoring the second tissue anchor comprises anchoring thesecond tissue anchor to the posterior annulus of the heart by deployingat least part of the anchor within the left atrium, such that thetensile member extends from the first tissue anchor, over an atrial sideof a posterior leaflet of the mitral valve, and to the second tissueanchor.
 40. The method according to claim 39, wherein the tensile memberis a suture, and wherein anchoring the second tissue anchor comprisesanchoring the second tissue anchor to the posterior annulus of the heartby deploying at least part of the anchor within the left atrium, suchthat the suture extends from the first tissue anchor, over an atrialside of a posterior leaflet of the mitral valve, and to the secondtissue anchor.
 41. The method according to claim 32, wherein the implantincludes a wire that extends between the first tissue anchor and thesecond tissue anchor, and wherein anchoring the second tissue anchorcomprises anchoring the second tissue anchor to the posterior annulus ofthe heart by deploying at least part of the anchor within the leftatrium, such that the wire extends from the first tissue anchor, over anatrial side of a posterior leaflet of the mitral valve, and to thesecond tissue anchor.